Nursing workload and patient-focused outcomes in intensive care: A systematic review

The aim of this systematic review was to examine the association of nursing workload on patient outcomes in intensive care units. The primary outcome measure was patient mortality, with adverse events (AE), the secondary outcome measures. Electronic search of databases including MEDLINE, CINAHL, Cochrane, EMCARE, Scopus, and Web of Science were performed. Studies were excluded if they were in non-ICU settings, pediatric, neonatal populations, or if the abstract/full text was unavailable. Risk of bias was assessed by the ROBINS-I tool. After screening 4129 articles, 32 studies were identified as meeting inclusion criteria. The majority of included studies were assessed as having a moderate risk of bias. The nursing activities score (NAS) was the most frequently used tool to assess nursing workload. Our systematic review identified that higher nursing workload was associated with patient-focused outcomes, including increased mortality and AE in the intensive care setting. The varied approaches of measuring and reporting nursing workload make it difficult to translate the findings of the impact of nursing workload on patient outcomes in intensive care settings.     

Measuring nursing workload in intensive care: an observational study using closed circuit video cameras

BACKGROUND: There is an increasing demand for intensive care provision in the United Kingdom (UK), partly because of a national shortage of intensive care beds. The problem is compounded by the current method for calculating the nurse: patient ratio using a Nurse Workload Patient Category scoring system or similar adaptations used in many intensive care units. This ratio is calculated by using patient category or dependency scales, which operate on the assumption that the more critically ill the patient, the more nurse time is needed to care for the patient. However, many mechanically ventilated critically ill patients (allocated a high category of care) may need less nursing care than patients who are self-ventilating and allocated a lower level of dependence. PURPOSE: In this study, a video recorder was used to document nurse activity for 48 continuous shifts in two intensive care units to determine the accuracy of the Nursing Workload Patient Category scoring system in measuring nurse workload. METHODS: The video data were correlated later with the Patient Category allocated to the patient by the nurse at the time. RESULTS: The results of this observational study demonstrated that, despite complex care needs, a high percentage of nursing activities observed in each unit consisted of low skill activity. Furthermore, nurses spent less time with patients categorized as in need of intensive care than those in need of high dependency care in both units. CONCLUSION: The findings suggest that existing nurse:patient ratio classifications may be inappropriate, since nurses spent less time with critically ill patients. Radical reconsideration of nursing levels and skill mix might make it possible to increase intensive care provision because fewer nurses would be needed to staff each bed. The findings support alternative and more flexible systems for assessing workload and the use of different nurse:patient ratios.     

Measuring nursing workload in neonatal intensive care

AIM: To determine if a suitable method of measuring nursing workload could be developed in neonatal intensive care units (NICUs). BACKGROUND: Nursing is a multifunctioning activity and previous methods measuring the demand for nurses do not put enough emphasis on the individual capabilities. The reporting of NICU activity has traditionally been related to bed occupancy and the number of infants requiring ventilator support. A classification system based on activity, hours of care and nursing staff ratios has been used; however, it does not consider the clinical ability of the individual nurses. METHODS: A 5-month prospective study was undertaken in which nurses in two NICUs scored their patients' level of dependency and professional assessment of the level of intensity of care required by the infants in each shift. In addition, serial measures of severity of illness scores for each patient were collected. KEY ISSUES: The study identified methods of measuring workload that consider the individual nurse's ability and contributing organizational factors. We found that the estimates of nursing hours using the two traditional dependency measures did not match the current practice or take into account the skill of the nurses. A method in which the nurses indicated the intensity of nursing care required by their patients was suitable one for capturing their individual capabilities. System factors were also found to contribute to the nursing workload. CONCLUSIONS: It is not sufficient to use patient acuity or severity of illness alone. Other factors such as the nurse's assessment of the intensity of care required and the organizational factors are important components of workload estimates.     

急诊重症监护病房患者的护理管理

目的探讨急诊及重症监护病房（ICU）监护患者的护理管理。方法对514例急诊ICU监护患者的临床护理管理进行回顾性分析。结果514例急诊ICU监护患者在护士的密切观察和严格护理管理下，家属满意度为99％。结论加强急诊ICU监护患者的护理管理，是减少患者在住院期间护理差错和纠纷的关键，值得临床推广。     

Nursing activities in intensive care units in Turkey

This cross-sectional study was conducted to determine applications practiced by nurses working in intensive care units of various institutions in Turkey. The research setting was neurosurgery, surgery, coronary and general intensive care units. The population of the study comprised nurses working in intensive care units, which were under the scope of this study, and these nurses' functions were studied. Data were collected using a Personal Information Form, the Cheltenham Patient Classification Scale and Nursing Activity List. It was observed that nurses spend most of their time on direct nursing care, clerical nursing duties and patient assessment. The most frequent activities included recording observations, calculating fluid balance, recording ventilator parameters, talking to patients, conversation not task orientated, drug preparation and administration. Although nurses spend most of their time on direct nursing care, they might also be obliged to get around to activities not in relation with direct patient care.     

Correlation between the TISS‐28 and NEMS indicators in an intensive care unit

Cross‐sectional study aimed at to analyse and compare the correlation between the Therapeutic Intervention Scoring System (TISS)‐28 and Nine Equivalents of Nursing Manpower Use (NEMS) indicators with a sample of 725 patients, for which data was collected from the computerized system of a university hospital. The findings of the present study well demonstrated a strong correlation between the TISS‐28 and NEMS, both at the time of patient admission and discharge (0.888 and 0.885; P < 0.001), although there is a dispersion of 21% in the data and established cut‐off points to discriminate with greater power the death and no death scenarios. Further research is still necessary to confirm the possibility of replacing the TISS‐28 scoring instrument with NEMS.     

Nurse decision-making when managing noradrenaline in the intensive care unit: A naturalistic observational study

ObjectiveIntensive care nurses care for critically ill patients in a complex, fast paced environment. Management of noradrenaline (norepinephrine) is core business for intensive care nurses and nurse decision-making on noradrenaline is poorly understood. The study objective was to investigate decision-making processes nurses use when caring for intensive care unit patients receiving noradrenaline.Research MethodologyA qualitative exploratory design used the Cognitive Continuum Theory as a framework for naturalistic observations and interviews in two medical/surgical intensive care units in Melbourne, Australia.Main Outcome MeasuresObservational and interview data from field notes and audiovisual recordings were transcribed and coded to develop themes using reflexive thematic analysis.FindingsFourteen nurse and patient dyads were recruited to observational sessions from December 2019 to June 2021. Three major themes developed were Learning through doing; Individualised patient care; and Clinical expertise, with six supporting sub-themes. Nurses learned to manage noradrenaline experientially and developed titration and weaning strategies to support decision-making. Blood pressure targets and monitor alarms were used consistently to aid decision-making processes. Nurses were observed practicing across the cognitive continuum depending on knowledge structure, complexity of interventions, response time, and patient acuity.ConclusionExperiential learning of complex and high-risk interventions in the absence of guidelines or algorithms meant nurses developed their own titration and weaning strategies based on constant evaluation and re-evaluation of patient cues. Patient heterogeneity, cue ambiguity and a dynamic practice environment contributed to decision-making complexity that would benefit from development of evidence-based practice resources.Implications for Clinical PracticeNurses learn to manage noradrenaline through experiential learning, using blood pressure targets and monitor alarms to support decision-making when titrating and weaning noradrenaline. Nurses develop noradrenaline titration and weaning strategies to support decision-making in the absence of guidelines or algorithms. Supporting nurse decision-making and streamlining practice would reduce practice variation and cognitive workload.     

TISS在SICU护理工作量评定与分析中的应用

目的：应用治疗干预计分系统（TISS）评定、分析外科重症监护病房（SICU）的护理工作量,为临床管理提供客观参考依据。方法：观察北京某三级甲等医院SICU半年内每天的护理记录并收集366例患者每天的TISS计分,统计SICU病房每天所有患者的TISS总分。结果：根据TISS给定的分级方法,826例次SICU患者的TISS计分均数为39.52,约需要1：1的护患比。其中有46.97%例次的TISS计分在40～87分之间,属于TISS分类Ⅳ级的重患者,需要1名或者1名以上的护士直接护理。SICU每天护理工作总量的TISS计分均数为195.74,每天满足患者直接护理需要的护士岗位职数为15人。TISS的76个护理干预项目中,心电图监护、每24小时的常规摄入及排出、留置导尿管的操作频次占前3位。结论：SICU护士处于超负荷工作状态。TISS为SICU护理工作量的评估和人力资源的合理使用提供了有力的依据;护患比例失调,护士编制不足,是监护病房亟待解决的问题。     

Nursing diagnoses in patients having mechanical ventilation support in a respiratory intensive care unit in Turkey

This research was carried out to find out the nursing diagnoses in patients who have mechanical ventilation support in a respiratory intensive care unit. The study was conducted with 51 evaluations of critically ill adult patients who underwent invasive and non-invasive mechanical ventilation therapy in 2008. Data collection was based on Gordon's 11 Functional Health Patterns, and nursing diagnoses were determined according to North American Nursing Diagnosis Association-International (NANDA-I) Taxonomy II. The nursing diagnoses were determined by two researchers separately. The consistency between the nursing diagnoses defined by the two researchers was evaluated by using Cohen's kappa (κ). Forty men (78.4%) and 11 women (21.6%) whose mean ages were 70.19 (SD = 8.96) years were included in the study. Nineteen subgroups of nursing diagnoses about safety/protection domain, and 15 subgroups about activity/rest domain were seen at different rates in the patients. There was a statistically significant difference between mechanical ventilation via tracheostomy or endotracheal tube and decreased cardiac output (d.f. = 1, χ(2) = 4.760, P = 0.029). The relationship between the length of time under mechanical ventilation and impaired physical mobility was considerably significant (d.f. = 3, χ(2) = 24.459, P = 0.000). It was found out that there was a high degree of agreement (96.8%) between the nursing diagnoses defined by the two researchers separately (κ = 0.936, SE = 0.08).     

Physical restraints practice in adult intensive care units in Egypt

Physical restraints are commonly used in intensive care units to reduce the risk of injury and ensure patient safety. However, there is still controversy regarding the practice of physical restraints in such units. The purpose of this study was to investigate the practices of physical restraints among critical care nurses in El‐Mansoura City, Egypt. The study involved a convenience sample of 275 critically ill adult patients, and 153 nurses. Data were collected from 11 intensive care units using a “physical restraint observation form” and a “structured questionnaire.” The results revealed that physical restraint was commonly used to ensure patient safety. Assessment of physical restraint was mainly restricted to peripheral circulation. The most commonly reported physically restrained site complications included: redness, bruising, swelling, and edema. The results illustrated a lack of documentation on physical restraint and a lack of education of patients and their families about the rationale of physical restraint usage. The study shed light on the need for standard guidelines and policies for physical restraint practices in Egyptian intensive care units.     

Person-centred care among intensive care unit nurses: A cross-sectional study

ObjectivePractising person-centred care is crucial for nurses in the intensive care unit, as patients have high physical and psychological care needs. We aimed to identify the predictors of person-centred care among nurses working in intensive care settings.MethodsIn this cross-sectional study, 188 intensive care unit nurses at four tertiary hospitals in two cities of South Korea were included. They completed self-reported questionnaires on emotional intelligence, compassion satisfaction, secondary traumatic stress, burnout, and person-centred care. Emotional intelligence was measured using the Korean version of the Wong and Law’s emotional intelligence scale. Compassion satisfaction, secondary traumatic stress, and burnout were measured by the Professional Quality of Life questionnaire (version 5). Person-centred care was measured using the person-centred critical care nursing scale.ResultsMultiple regression identified compassion satisfaction (β = 0.49, p <.001) as the most powerful predictor of person-centred care, followed by emotional intelligence (β = 0.21, p =.004) and intensive care unit career length (β = 0.17, p =.021). These three variables accounted for 31.0 % of the variance in person-centred care.ConclusionsThis study highlights the importance of career length, emotional intelligence, and compassion satisfaction in the promotion of person-centred care among intensive care unit nurses. Nursing management should contemplate specific measures to reduce turnover among experienced intensive care unit nurses and to enhance the factors that promote person-centred care, such as compassion satisfaction and emotional intelligence.